Anatomic And Physiologic Considerations

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Many of the complications of esophageal surgery are related directly to the unique features of esophageal anatomy and physiology. A thorough understanding and appreciation of these characteristics allows the informed esophageal surgeon to think and act defensively, thus averting complications before they occur. In performing esophagoscopy, for example, one must bear in mind the three naturally occurring sites of esophageal narrowing: the upper esophageal introitus, or cricopharyngeal sphincter; the level of the aortic arch and left mainstem bronchus; and the esophagogastric junction ( Fig. 26-1 ). The rigid esophagoscope must be manipulated appropriately through these points of narrowing to minimize the risk of injury during esophagoscopy. Another unique feature of esophageal anatomy is its unusually fatty submucosa, which allows relatively great mobility of the overlying squamous mucosa. In performing a manual esophageal anastomosis, particular care must be exercised to make sure that every suture transfixes the mucosal edge, which at times may retract more than 1 cm away from the cut esophageal margin ( Fig. 26-2 ). Postoperative esophageal anastomotic leaks are most often related to technical errors, and there is simply no substitute for meticulous technique and attention to detail in esophageal surgery.

Suture line tumor recurrence after an esophagectomy for carcinoma is a terrible late complication of esophageal surgery that is related directly to anatomic considerations, in this case, the extensive submucosal lymphatic drainage of the esophagus. The well-known propensity of esophageal tumor cells to spread through the submucosal lymphatics 4 to 6 cm and more beyond gross neoplasm has justified the mandate that, whenever possible, a 6- to 10- cm margin be obtained beyond the tumor before constructing the anastomosis ( Fig. 26-3 ). The esophagus is also unique in the gastrointestinal tract because it lacks a serosal layer. The rather soft and often tenuous esophageal muscle holds sutures poorly and cannot be relied on to maintain a fundoplication, for example, unless the associated submucosa is transfixed by the esophageal stitch.

The esophagus is nourished by four to six paired aortic esophageal arteries as well as collateral circulation from the inferior thyroid, intercostal and bronchial, inferior phrenic, and left gastric arteries. The segmental "poor" blood supply of the esophagus has frequently been incriminated as the cause of anastomotic disruption. This contention is simply unjustified. The submucosal collateral circulation of the esophagus is extensive, and even after the cardia has been divided and the intrathoracic esophagus mobilized completely out of the chest, the distal end of the esophagus maintains good arterial bleeding so long as the inferior thyroid arteries remain intact. Once again, poor technique, not poor blood supply, is the more likely explanation for the complication of esophageal anastomotic disruption. Finally, parasympathetic

Figure 26-1 Normal esophageal constrictions, dilatations, and measurements. (From Shackelford, R.T. fed.]: Surgery of the Alimentary Tract, Vol 1, 2nd ed. Philadelphia, W.B. Saunders, 1978, p. 9, with permission.)

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Physiologic Narrowings The Esophagus

Figure 26-2 Failure of an esophageal anastomotic suture to transfix the mucosa is a function of the fatty submucosa, which permits mobility of the overlying mucosa and allows its retraction. The mucosa must be identified and deliberately transfixed with each suture placed to achieve mucosal apposition and avoid an anastomotic leak. (From Orringer, M.B.: Complications of esophageal surgery and trauma. In Greenfield, L.J. [ed.]: Complications in Surgery and Trauma. Philadelphia, J.B. Lippincott, 1984, p. 261, with permission.)

Figure 26-3 Intrathoracic esophagogastric anastomotic stricture (arrow) due to recurrent tumor at the suture line. This patient had undergone an esophagogastrectomy for a distal-third esophageal adenocarcinoma 7 months earlier. An Insufficient 3-cm esophageal margin proximal to the tumor had been obtained, and palliation of dysphagia was short-lived.

Figure 26-4 Posteroanterior (left) and lateral (right) views from a barium swallow examination showing a sliding hiatal hernia with a midesophageal stricture (arrow) at the squamocolumnar junction in a patient with Barrett's esophagus. Standard antireflux operations (Hill, Belsey, or Nissen) require reduction below the diaphragm of not only the esophagastric junction but also the distal 3 to 5 cm of esophagus. The esophageal shortening and periesophageal fibrosis due to reflux esophagitis in this patient prevented a tension-free standard repair.

Figure 26-5 Development of a recurrent hiatal hernia after a Hill posterior gastropexy for reflux esophagitis with a stricture. Left, There is a sliding hiatal hernia above the diaphragm (smallarrow) as well as a reflux stricture (large arrow). This patient was obese and had distal esophagitis and associated esophageal shortening. Center, One week after a Hill repair, there already is little evidence of an intra-abdominal distal esophageal segment. Right, Within 1 year of performing this hiatal hernia repair under tension, disruption has occurred, and the stomach is seen above the diaphragm (arrow). (From Orringer, M.B.: Complications of esophageal surgery and trauma. In Greenfield, L.J. [ed.]: Complications in Surgery and Trauma. Philadelphia, J.B. Lippincott, 1984, p. 262, with permission.)

Figure 26-6 Slipped Nissen fund op li cation in a patient who was operated on for reflux complicated by a short esophagus and stricture. Tension on the repair resulted in its subsequent disruption. The proximal stomach has herniated through the fundo plication (arrow) and is seen above the level of the diaphragm.

Figure 26-7 Construction of the Collis gastroplasty using the GIA surgical stapler. A, The sixth left interspace incision used. B, The esophageal dilator (No. 54 or 56 French) is displaced against the lesser curvature of the stomach; dotted line indicates where the stapler will be applied. Main illustration, Advancing the knife assembly for construction of the gastroplasty tube. C, The 5-cm gastric tube extension of the functional esophageal tube. (From Orringer, M.B., and Sloan, H.: An improved technique for the combined Collis-Belsey approach to dilatable esophageal strictures. J. Thorac. Cardiovasc. Surg., 68:298, 1974, with permission.)

Figure 26-8 A, The elongated gastric fundus remaining after construction of the gastroplasty tube. The staple suture line has been oversewn. B and C, Positioning the gastric fundus posterior to the gastroplasty tube in preparation for the fundoplication. (From Orringer, M.B., and Sloan, H.: Combined Collis-Nissen reconstruction of the esophagogastric junction. Ann. Thorac. Surg., 25:16, 1978, with permission.)

Figure 26-9 Construction of a 3-cm-long fundoplication to complete the Collis-Nissen operation. A, Four seromuscular 2-0 silk sutures placed 1 cm apart are used. B, The fundoplication is placed beneath the diaphragm, and the previously placed posterior crural sutures are tied. (From Stirling, M.C., and Orringer, M.B.: The combined Collis-Nissen operation for esophageal reflux strictures. Ann. Thorac. Surg., 45:148, 1988, with permission.)

TABLE 26-1 -- Causes of Esophageal Perforation

Instrumental

Endoscopy

Direct injury

Injury occurring during removal of a foreign body

Intubation (esophageal, endotracheal)

Noninstrumental

Barogenic trauma

Blunt chest or abdominal trauma

Other (e.g., labor, convulsions, defecation)

Penetrating neck, chest, or abdominal trauma

Postsurgical

Anastomotic disruption

Devascularization after pulmonary resection, vagotomy, or repair of a hiatal hernia

Corrosive injuries (acid or alkali ingestion)

Erosion by adjacent infection with resultant fistula involving the tracheobronchial tree, pericardium, pleural cavity, or aorta

the same as that imposed by elective esophagotomy and primary esophageal closure. If surgery is delayed more than 6 to 8 hours from the time of injury, local inflammation greatly jeopardizes primary healing of the esophageal tear, and the mortality rate rises dramatically.

Figure 26-10 Posteroanterior (left) and lateral (center) views from Gastrografin swallow in a patient with acute caustic injury that was incorrectly dilated prematurely within 10 days of Drano ingestion. There was still acute inflammation in this esophagus, and the patient had a fever and chest pain after the dilation. Despite the negative Gastrografin swallow, dilute barium was administered (right), and a perforation

(arrow) of the mid esophagus was demonstrated. (From Orringer, M.B.: Complications of esophageal surgery and trauma. In Greenfield, L.J. fed. J: Complications in Surgery and Trauma. Philadelphia, J.B. Lippincott, 1984, p. 270, with permission.)

Dilatation

Postemetic

Figure 26-11 Surgical approach to the perforated cervical esophagus. A, Skin incision along anterior border of left sternocleidomastoid muscle from the level of the cricoid cartilage to the sternal notch. B, Blunt dissection into superior mediastinum along the prevertebral fascia medial to the sternocleidomastoid muscle and carotid sheath. Injury to the recurrent laryngeal nerve in the tracheoesophageal groove must be avoided. C, Schematic view of prevertebral space to be drained. D, Placement of two 1-in rubber drains to allow establishment of an esophagocutaneous fistula. (From Orringer, M.B.: The mediastinum. In Nora, P.F. fed.]: Nora's Operative Surgery, 3rd ed. Philadelphia, W.B. Saunders, 1990, p. 370, with permission.)

Figure 26-12 Technique of primary repair of esophageal perforation. The pouting mucosa at the site of the tear (inset) is grasped with Allis clamps (A), and the adjustment esophageal muscle is mobilized around the entire tear with a right-angle clamp until 1 cm of normal submucosa is exposed around the defect (B). (From Whyte, R.I., lannettoni, M.D., and Orringer, M.B.: Intrathoracic esophageal perforation: The merit of primary repair. J. Thorac. Cardiovasc. Surg., 109:140, 1994, with permission.)

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